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Part 1 and Part 2 UPDATE, Emergency Trauma Puzzle: How would you treat it?

Craig Barrington, DDSInstructional, Trauma Management, Recall Observations, Sample Cases, All by Date

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Full mouth set of preoperative radiographs (1992)

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Preoperative periapical radiograph of the mandibular anterior sextant (post-accident showing the fractured jaw down the mid-line with the fracture lines extending distally, night of accident on 2/26/2006)

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Preoperative periapical radiograph of the mandibular left posterior sextant (2/26/2006, showing the fracture line extending distally along the lower left quadrant - it raised the question of whether the teeth were fractured in addition to the jaw or just the jaw)

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Periapical fistula tracing radiograph of the maxillary right first bicuspid (tooth #5, 9/26/2006)

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Fractured maxillary left first molar (tooth #14, 6/26/2006)

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Fractured maxillary left first bicuspid (tooth #12, 6/27/2006 when the patient returned the next morning after the accident)

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Fractured maxillary left canine ( tooth#11, 6/27/2006 when the patient returned the morning after the accident)

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Cracked layer of enamel removed from tooth #14 (6/28/2006)

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Enamel layer bonded back onto the facial of #14 (6/28/2006)

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Cracked layer of enamel removed from tooth #12 (6/28/2006)

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Enamel layer bonded back onto the facial of #12 (6/28/2006)

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Cracked layer of enamel removed from tooth #11 (6/28/2006)

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Enamel layer bonded back onto the facial of #11 (6/28/2006)

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Methylene blue dye staining of the crack in the crown of tooth #5 (8/26/2006)

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Rubber dam isolation and initial endodontic access of tooth #5 (9/14/2006)

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Microscopic inspection of the root canal system revealed a deep split in the buccal canal orifice with 3-canal bicuspid root form (9/14/2006)

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Incomplete crown-root fracture visualized through the endodontic access of tooth #5 (9/14/2006)

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Incomplete crown-root fracture visualized through the endodontic access of tooth #5 (9/14/2006, zoom view)

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Cone fit periapical radiograph (9/14/2006)

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Prepared crown of tooth #5 with bonded resin in access (9/28/2006)

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Prepared crown of tooth #5 with bonded resin in access (zoomed view, 9/28/2006)

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Immediate post-treatment periapical radiograph (tooth #5, 9/28/2006)

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Immediate post-treatment periapical radiograph (tooth #5, additional view on 9/28/2006)

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Recall periapical radiograph of tooth #5 with the patient still having symptoms (2/13/2007)

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CBCT capture sections (tooth #5, 3/22/2007)

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CBCT frontal capture section (tooth #5, 3/22/2007)

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Surgical access showing the fenestrated buccal root (tooth #5, 3/22/2007)

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Apicoectomy with MTA reverse-filling (tooth #5, 3/22/2007)

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Apicoectomy with MTA reverse-filling (tooth #5-zoomed view, 3,22/2007)

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Immediate post-surgical periapical radiograph (tooth #5, 3/22/2007)

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Follow-up periapical radiograph of the lower right sextant demonstrating healing of any fractures that may have extended into this region (6/1/2007)

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Recall periapical radiograph (mandibular anterior sextant, 6/1/2007)

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Recall periapical radiograph (mandibular left posterior sextant, 6/1/2007)

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Recall periapical radiograph (mandibular right posterior sextant, 6/1/2007)

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7-year recal clinical microphoto (tooth #14, 2/3/2015)

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7-year recall clinical microphoto (tooth #12, 2/3/2015)

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7-year recall clinical microphoto (tooth #12, 2/3/2015)

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7-year recall clinical microphoto (tooth #11, 2/3/2015)

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7-year recall clinical microphoto (tooth #11, 2/3/2015)

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7-year recall clinical microphoto (maxillary left region, 2/3/2015)

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7-year recall clinical microphoto showing healing of the maxillary arch, 2/3/2015

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7-year recall bitewing radiograph (right posterior areas, 2/3/2015)

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7-year recall periapical radiograph (tooth #5, 2/3/2015)

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PART 1

Patient: 40 year-old male with non-contributory medical history

Chief Complaint: “”I broke some of my teeth”

Dental History: The patient contacted the author on a Friday evening noting that he had been hit in his lower jaw with a barb wire fence tensioning tool. The trauma force vector was directed below the center of his lower jaw. The force caused his mouth to shut with a high speed which shattered multiple maxillary teeth. The patient was able to drive himself and meet the author at the office. He reported only minor restorative dentistry in his recent past dental history.

Significant Findings:

The patient presented with multiple bleeding lacerations below his mandible. There was bleeding from the patient’s mouth and he presented chips fragments of his teeth in his hand. He was unable to close the jaws in his normal occlusion and he was notably confused and fearful. The uninvolved teeth appeared healthy with excellent oral hygiene.

The lower central incisors (teeth#’s 24, 25) were rotated out of position with no enamel or root fractures. The buccal enamel shell appeared to be sheared from the upper left canine (tooth #11), upper left second premolar (tooth #13) and the distobuccal cusp of the upper right first molar (tooth #3). The enamel face of multiple teeth in the upper left quadrant was still present and attached only by the gingiva. The upper right first premolar (tooth #5) presented with a vertical split. Most of the damaged teeth seemed to have sheared off enamel except for the upper right first premolar. No pulp exposures were noted. A periapical radiograph of the lower central incisors (teeth #’s 24, 25 revealed a jaw fracture in the midline between the two teeth branching to the left and the right areas of the mandible. No mobility of any teeth was noted. All the teeth involved were percussion sensitive and air sensitive with a transient, non-lingering response.

Later the upper right first premolar (tooth #5) would present with buccal sinus tract

How would you systematically manage this patient?

PART 2
Pulp and Periradicular Diagnosis: :

Tooth #3-reversible pulpitis with a normal periradicular periodontium – enamel fracture
Tooth #5-reversible pulpitis with a normal periradicular periodontium cracked tooth (later progressed to pulpal necrosis/chronic periradicular periodontitis)
Tooth #11- reversible pulpitis with a normal periradicular periodontium -enamel fracture
Tooth #12- reversible pulpitis with a normal periradicular periodontium -enamel fracture
Tooth #13-reversible pulpitis with a normal periradicular periodontium -enamel fracture
Tooth #14-reversible pulpitis with a normal periradicular periodontium -enamel fracture
Tooth #24-reversible pulpitis/acute periradicular periodontitis- lateral luxation
Tooth #25-reversible pulpitis/acute periradicular periodontitis -lateral luxation
Tooth #19-reversible pulpitis/acute periradicular periodontitis -concussion
Tooth #20-reversible pulpitis/acute periradicular periodontitis -concussion
Tooth #28-reversible pulpitis/acute periradicular periodontitis -concussion
Tooth #29-reversible pulpitis/acute periradicular periodontitis -concussion
Tooth #30-reversible pulpitis/acute periradicular periodontitis -concussion

A simple comminuted fracture of the lower jaw was noted

Treatment Prognosis:

Tooth #’s 3, 11, 12, 13, and 14- excellent prognoses
Teeth #’s 24 and 25 – good prognoses
Tooth #5-guarded to poor prognosis (initial assessment)
Teeth #’s 19, 20, 28, 29, and 30 – guarded prognoses (questionable whether root fractures were associated with jaw fractures)

Treatment Plan: :

a. Refer to an oral surgeon for fixation/treatment of the jaw fracture.
b. Reposition teeth #’s 24,25 with splinting.
c. Evaluation and re-evaluation of the pulpal status of the lower molars and premolars.
d. Bond the enamel fragments to the crown on teeth #’s 3, 11, 12, 13, 14.
e. Exploratory endodontic access (tooth # 5) with decision points re-evaluating the healing/prognosis to decide whether to perform definitive nonsurgical endodontic therapy or extraction.

Special Considerations of Performed Treatment:

The complexity of the presentation involving multiple teeth required emergency triage and prioritization of treatments. After fixation of the jaw fracture and splint of the two mandibular central incisors, monitoring and evaluation of the teeth in the “impact zone” was required as it was unknown which additional teeth may reveal root future evidence of root fractures. Observation of all affected teeth was prescribed. Bonding the sheared off enamel back onto the crowns reduced the symptoms and restored the occlusion so that the patient was returned to function.

The upper right first premolar (tooth #5) became the next treatment priority. The subgingival/subosseous extent of the crack was unknown. The root canal system presented with challenging anatomy. A sinus tract persisted after nonsurgical endodontic therapy. An ICAT CBCT scan became available and revealed a furcation radiolucency. The author performed a surgical exploration of the root and found the buccal root to have a limited fracture which was treated with apical resection and reverse-filling with MTA. Healing was uneventful and the patient remained asymptomatic so a crown restoration was placed.

Recall:

Seven years after the trauma and treatment the #5 tooth remained functional, asymptomatic, and without associated pathosis. The upper left teeth responded normally to vitality and percussion testing. Continued recall observation is scheduled.

Key Learning Points:

  1. Trauma can be confusing for all the individuals involved. Time is a great healer

  2. Due to the unusual nature of trauma, unusual treatment modalities can be useful and effective long term

  3. Long term recall evaluation of trauma cases is a necessary ongoing requirement
  4. CBCT technology is a useful modern technological tool but has its limitations in definitively detecting root fractures

  5. Endodontic anatomy can be complex but with meticulous management, teeth can be predictably saved with endodontic therapy

Join the discussion

Excellent management: diagnoses; treatments undertaken, and appropriate referral. The prognoses are suitable but as indicated in the KLPs, time is the great decider/healer. Create suitable conditions for healing and let "Mother Nature" take over. The patient is probably very fortunate that they did not see a maxillofacial surgeon first!

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